CLINICAL ARTICLE

J Neurosurg 131:1227–1234, 2019

Contralateral progression after unilateral evacuation

of bilateral chronic subdural hematomas: the volume
relation ratio as prognostic factor?
Florian Scheichel, MD,1,2 Branko Popadic, MD,1,2 Karl Ungersboeck, MD,1,2 and Franz Marhold, MD1,2
1
Department of Neurosurgery, University Hospital of St. Poelten; and 2Karl Landsteiner University of Health Sciences, Krems an
der Donau, Lower Austria, Austria

OBJECTIVE Unilateral evacuation of bilateral chronic subdural hematomas (bcSDHs) is associated with higher retreat-
ment rates than an initial bilateral intervention. One reason for that is a possible progression in the size of the contralat-
eral side after unilateral treatment. Thus, the authors focused their study on finding predictors of the need for contralat-
eral retreatment.
METHODS All patients who had undergone unilateral or bilateral evacuation of bcSDHs in the Department of Neuro-
surgery at the University Hospital of St. Poelten during a 5-year period (7/2012 to 6/2017) were retrospectively identified.
The preoperative hematoma volume was calculated using the XYZ/2 method.
RESULTS Of a total of 103 patients with bcSDHs, 61 patients underwent bilateral evacuation and 42 patients underwent
unilateral evacuation. The retreatment rate after bilateral evacuation was significantly lower than that after unilateral
evacuation (14.8% vs 31%, respectively; p = 0.049). Contralateral retreatment after unilateral evacuation was necessary
in 9 patients (21.4%). The preoperative contralateral hematoma volume was significantly higher in those patients who
needed contralateral retreatment after initial unilateral evacuation (68.4 cm3 vs 27.4 cm3, respectively; p < 0.001). Fur-
thermore, the so-called volume relation ratio created by dividing the smaller by the larger hematoma volume was signifi-
cantly higher when contralateral retreatment became necessary (0.56 vs 0.21, respectively; p < 0.001).
CONCLUSIONS Patients needing evacuation of bcSDHs should be considered for primary bilateral evacuation if the
hematoma volume on the smaller side is greater than 40 cm3 and the subsequent volume relation ratio is greater than 0.4.
https://thejns.org/doi/abs/10.3171/2018.6.JNS18467
KEYWORDS chronic subdural hematoma; bilateral; retreatment; trauma

C
hronic subdural hematoma (cSDH) is a common
diagnosis in neurosurgery. The incidence is up to
13.1 per 100,000/year with an increase in the el-
derly.4,5,8 A cSDH is a slowly progressive collection of
liquefied SDH arising in 50% to 80% after minor head
trauma.4,14,18 The time interval from trauma to onset of
symptoms is often delayed. Known additional risk factors
are antiplatelet or anticoagulant therapy, age, and brain at-
rophy.4,14
Bilateral cSDHs (bcSDHs) account for 17.4%–34.9% of
cSDH cases.7,17,19,21
Although there is no standardized treatment for cSDH
and bcSDH, indication for surgery is generally accepted
in symptomatic patients. Various surgical techniques have
been used for years. Burr hole craniostomy with or without
insertion of a closed drainage system is the most frequent
performed procedure.9,20
However, recurrence of cSDH requiring ipsilateral re-
operation is common. The reported rate ranges from 9.2%
to 26.5%.1,2,10–12,15 Moreover, in bcSDHs the retreatment
rate reaches almost 30%.7,13,19 Noted retreatment rates for
bcSDHs in the literature depict both surgery for ipsilat-
eral recurrence and surgery for contralateral progression
after initial unilateral hematoma evacuation. Because of

ABBREVIATIONS bcSDH = bilateral chronic subdural hematoma; CCT = cranial CT; cSDH = chronic subdural hematoma; ICP = intracranial pressure; VR-ratio = volume
relation ratio.
SUBMITTED February 18, 2018. ACCEPTED June 12, 2018.
INCLUDE WHEN CITING Published online November 23, 2018; DOI: 10.3171/2018.6.JNS18467.

©AANS 2019, except where prohibited by US copyright law J Neurosurg Volume 131 • October 2019 1227

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Scheichel et al.
their different underlying pathomechanisms, ipsilateral
recurrence and contralateral progression should be distin-
guished.
Recently, unilateral evacuation of bcSDHs has been
identified as an independent risk factor for retreatment.3
For all patients requiring retreatment after unilateral
evacuation of a bcSDH, more than 50% need contralateral
hematoma evacuation.3 Thus, it seems crucial to identify
those patients who could profit from initial bilateral evac-
uation.
To the best of our knowledge, there are no distinct pa-
rameters predicting a contralateral progression after uni-
lateral evacuation of bcSDHs. The decision whether to
evacuate one or both sides initially is mainly based on the
size of each hematoma, mass effect demonstrated on im-
aging studies, and lateralization of symptoms. There are
no standardized parameters that could be used repeatedly
in different patients.
Therefore, we focused in this analysis on finding pre-
dictors for contralateral retreatment in bcSDHs after uni-
lateral evacuation.
Methods
We performed a retrospective single-center analysis of
all surgically treated patients with bcSDHs from July 1,
2012, to June 30, 2017, at the University Hospital of St.
Poelten, Austria (Karl Landsteiner Private University of
Health Sciences). This study was approved by the ethics
commission of Lower Austria, Austria. A database query
searching for specific treatment codes (craniostomy, cra-
niotomy) was performed to identify those patients treated
for cSDH, either cSDH or bcSDHs, during this 5-year pe-
riod consecutively. To identify all patients with bcSDHs,
the latest cranial CT (CCT) scan obtained prior to sur-
gery was reviewed, and only patients with bcSDHs were
included in the study.
The exclusion criteria were patient age younger than 20
years, a history of ventricular shunt implantation, and de-
compressive craniectomy or any other previous cranioto-
my due to a possibility of a difference in pathophysiology.
In patients harboring a possible acute SDH, all the data
were meticulously reviewed. In cases of a cSDH, which
appeared dubious, the patients were excluded.
The mean radiological follow-up duration was 172.8
days.
Preoperative Imaging
All patients underwent CCT before surgery. We ana-
lyzed the cSDH in terms of acuity, size, volume, location
density, and midline shift on the last CCT scan before sur-
gery.
The hematoma density of each side was classified as
homogeneous, separated, laminar, or membranous based
on the description of Nakaguchi et al.10 The preopera-
tive hematoma volumes were calculated on the last CT
scan acquired before surgery using the XYZ/2 method,
which has been described to be valid for cSDH by Sucu
et al.16 To calculate the hematoma volume, we identified
the depth by multiplying the number of axial slices on
which the hematoma was visible with the slice thickness.
1228 J Neurosurg Volume 131 • October 2019
The depth was multiplied by the maximum length on any
slice and the maximum width on any slice and then di-
vided by 2.
Volume Relation Ratio
To determine if there was interaction between the indi-
vidual volume and mass effect of both hematomas, we de-
fined a variable called the volume relation ratio (VR-ratio).
The VR-ratio was calculated by dividing the volume of
the smaller contralateral hematoma by the volume of the
larger ipsilateral one. To the best of our knowledge, this
was done for the first time in cSDHs.
Patient Characteristics and Surgical Treatment
Demographic and clinical data including sex, age,
symptoms, anticoagulant or antiplatelet therapy, history of
head trauma, and outcome were culled from medical re-
cords. Surgical data included side of evacuation, surgical
procedure, and usage of a closed drainage system. Indica-
tion for surgery and the decision of whether to perform
burr hole craniostomies or craniotomies with or without
insertion of a drainage system were made by the attending
neurosurgeon.
The standard surgical procedure for cSDH at our in-
stitution consists of single– or double–burr hole cranios-
tomy and insertion of a closed drainage system. In cases
involving rather small hematoma volumes and intraop-
erative reexpansion of brain parenchyma after hematoma
evacuation, the attending surgeon could decide against a
drainage system when it could not be safely inserted. The
attending surgeon may have decided to perform a crani-
otomy in a case of distinct membranous cSDH.
Retreatment
Retreatment was defined as every subsequent surgery
necessary due to a progressive contralateral hematoma,
recurrence of the evacuated ipsilateral hematoma, or in-
complete evacuation of the ipsilateral hematoma with re-
maining mass effect. Information regarding retreatment
included side of retreatment (ipsi- or contralateral), time
to retreatment, and preoperative hematoma volume on the
latest CT scan before the second surgery for contralateral
retreatment. Follow-up CT scans and outpatient reports
were analyzed to find patients with recurrence.
Patients who had undergone unilateral hematoma
evacuation of bcSDHs were then divided into two groups:
group A included patients with contralateral retreatment
and group B included patients without contralateral re-
treatment. Attributes were compared between the groups
to find predictors for contralateral retreatment after unilat-
eral evacuation.
Statistical Analysis
For statistical analysis, we used SPSS statistical soft-
ware (IBM Corp.). For qualitative variables, a chi-square
test was performed; for continuous variables, a Student t-
test was executed. A p value < 0.05 was considered statis-
tically significant. Cutoff values were found with receiver
operating characteristic curve analysis.
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 Scheichel et al.

TABLE 1. Clinical, demographic, and surgical data TABLE 2. Comparison of groups A and B
No. of Cases or % or No. of Patients (%) or
Variable Mean Value SD Mean Value
Patients 103 100 Contralat No Contralat
Retreatment Retreatment p
Sex
Variable (%) (%) Value
Male 69 67.0
Female 34 33.0 Patients 9 (21.4%) 33 (78.6%)
Mean age in yrs 76.8 ±9.4 Sex NS
Clinical presentation Male 6 (66.7%) 20 (60.6%)
Headache 35 34.0 Female 3 (33.3%) 13 (39.4%)
Nausea & vomiting 7 6.8 Density of the contralat hema- NS
toma on preop CT scan
Hemiparesis 33 32.0
  Homogeneous 5 (55.6%) 14 (42.4%)
Neuropsychological changes 66 64.1
  Laminar 0 (0%) 12 (36.4%)
Clouding of consciousness 22 21.4
  Separated 3 (33.3%) 3 (9.1%)
CT density, right side
  Membranous 1 (11.1%) 4 (12.1%)
Homogeneous 43 41.7
Midline shift, mm 7.6 ± 5.8 7.4 ± 3.6 NS
Laminar 15 14.6
Anticoagulant or antiplatelet NS
Separated 29 28.2
therapy
Membranous 16 15.5
  Yes 8 (88.9%) 20 (60.6%)
CT density, left side
  No 1 (11.1%) 13 (39.4%)
Homogeneous 38 36.9
Side of evacuation NS
Laminar 22 21.4
Right 3 (33.3%) 14 (42.4%)
Separated 23 22.3
Left 6 (66.7%) 19 (57.6%)
Membranous 20 19.4
Surgical procedure NS
Surgery location
1–burr hole craniostomy 6 (66.7%) 18 (54.5%)
Unilateral evacuation 42 40.8
2–burr hole craniostomy 0 (0%) 9 (27.3%)
  Right 17
Craniotomy 3 (33.3%) 6 (18.2%)
  Left 25
Drain used NS
Bilateral evacuation 61 59.2
Yes 8 (88.9%) 31 (93.9%)
Mean preop hematoma vol, cm3
No 1 (11.1%) 2 (6.1%)
Bilateral evacuation
Ipsilat hematoma vol, cm3 121.0 ± 31.4 140.6 ± 48.3 NS
   Right hematoma vol 120.8 ±47.1
Contralat hematoma vol, cm3 68.4 ± 24.2 27.4 ± 15.9 <0.001
   Left hematoma vol 123.3 ±49.7
VR-ratio (smaller vol/larger vol) 0.56 ± 0.11 0.21 ± 0.12 <0.001
Right evacuation
   Right hematoma vol 136.6 ±40.3 NS = not significant.
Hematoma volumes and the VR-ratio are expressed as mean ± SD.
   Left hematoma vol 33.7 ±23.4
Left evacuation
   Right hematoma vol 38.7 ±25.8
   Left hematoma vol 136.3 ±49.7 Results
Surgical procedure in bilateral op A total of 103 patients with bcSDHs were included in
1–burr hole craniostomy 39 63.9 this study. Of these 103 patients, 69 (67%) were male and
2–burr hole craniostomy 15 24.6 34 (33%) were female. Their age ranged from 21.7 to 92.9
Craniotomy 7 11.5 years (mean 76.8 years). Preoperative antiplatelet or anti-
Drain 58 95.1
coagulant therapy was administered in 59 patients (57.3%).
Head trauma was noted in 73 patients (70.9%).
No drain 3 4.9 Clinical, demographic, and surgical data are summa-
Surgical procedure in unilateral op rized in Table 1.
1–burr hole craniostomy 24 57.1
2–burr hole craniostomy 9 21.4 Hematoma Volumes
Craniotomy 9 21.4 The mean hematoma volume was 120.8 cm3 (± 47.1
Drain 39 92.9 cm3 [SD]) on the right side and 123.3 cm3 (± 49.7 cm3)
No drain 3 7.1 on the left when bilateral evacuation was performed. In
patients who underwent unilateral evacuation, the mean
hematoma volumes were 136.6 cm3 (± 40.3 cm3) on the

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FIG. 1. Left: Box plot illustrating the preoperative contralateral hematoma volume in patients with and without contralateral
retreatment after unilateral evacuation of bcSDHs. Right: Bar graph showing contralateral retreatment rates for patients with a
preoperative contralateral hematoma volume of less than 40 cm3, between 40 and 60 cm3, and greater than 60 cm3. ccm = cubic
centimeters (cm3).
right side and 33.7 cm3 (± 23.4 cm3) on the left side after
right-sided evacuation and 38.7 cm3 (± 25.8 cm3) on the
right and 136.3 cm3 (± 49.7 cm3) on the left after left-sided
evacuation.
Side of Evacuation and Procedure
Initial bilateral hematoma evacuation was performed in
61 patients (59.2%), whereas initial unilateral evacuation
was performed in 42 patients (40.8%). Of these unilateral
evacuated bcSDHs, slightly more patients underwent left-
sided evacuation (59.5%, 25 cases) than right-sided evacu-
ation (40.5%, 17 cases).
In patients who initially underwent bilateral hematoma
evacuation, craniotomy on at least one side was performed
in 11.5% (7 cases), a single burr hole was made in 63.9%
(39 cases), and double burr holes were created in 24.6%
(15 cases).
In patients who underwent unilateral evacuation, cra-
niotomies were performed in 21.4% (9 cases), a single
burr hole was created in 57.1% (24 cases), and double burr
holes were made in 21.4% (9 cases).
A drainage system was used in 94.2% of the patients (n
= 97). In terms of frequency of drainage insertion, there
was no significant difference between patients who under-
went unilateral (92.9%, 39 cases) or bilateral (95.1%, 58
cases) evacuation.
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Retreatment Rates
The overall retreatment rate was 21.4% (22 cases). The
retreatment rate for patients who had undergone bilateral
evacuation was 14.8% (9 cases), which was significantly
lower than that for patients who had undergone unilateral
evacuation (31%, 13 cases) (p = 0.049). The majority of
these 13 cases (9 cases, 69.2%) needed retreatment on
the contralateral side, and the remaining 4 cases (30.8%)
needed ipsilateral retreatment.
Contralateral Retreatment After Unilateral Evacuation
The group that needed contralateral retreatment after
unilateral surgery (n = 9, group A) was compared with
the group that did not need contralateral retreatment (n =
32, group B). The results are listed in Table 2. Differences
in sex, density shown on the preoperative CT scan, anti-
coagulation and/or antiplatelet status, surgical procedure,
midline shift, and hematoma volume of the hematoma on
the evacuated side did not reach statistical significance.
The mean preoperative hematoma volume on the un-
treated, contralateral side was significantly larger in those
who needed contralateral retreatment (68.4 cm3 vs 27.4
cm3; p < 0.001).
The ratio between the smaller, contralateral hema-
toma volume and the larger, ipsilateral evacuated hema-
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 Scheichel et al.

toma volume was significantly higher in group A than in

group B and is therefore called VR-ratio (0.56 vs 0.21;
p < 0.001).
A cutoff value for the VR-ratio of 0.4 produced a sen-
sitivity of 1 and a specificity of 0.91 for contralateral re-
treatment (area under the receiver operating characteristic
curve 0.976, 95% CI 0.938–1.000; p < 0.001).
The mean time to contralateral retreatment after uni-
lateral evacuation was 28 days (± 16.7 days). In one patient
the hematoma volume before contralateral retreatment
could not be assessed because the patient only had hard
copies of the preoperative CT scans that were not acces-
sible retrospectively. The mean hematoma volume of the
progressive contralateral side of the remaining 8 patients
was 148.6 cm3 (± 39.5 cm3) on the CT scan obtained be-
fore reoperation.

Discussion
Despite the fact that cSDH is such a frequent condition
in neurosurgery, there is no standard protocol for decid-
ing in which patients surgical evacuation should be per-
formed. The decision is mainly based on parameters such
as the size of the hematoma, its mass effect, and midline
shift on CT scans, as well as neurological symptoms and
the patient’s clinical condition.
In patients with bcSDHs, focal neurological deficits are
less common, while symptoms due to high intracranial
pressure (ICP), such as vomiting and nausea, are more fre-
quent.7,17 Furthermore, midline shift is not as common and
distinct in cases of bcSDH.6,7,17
In our study the mean hematoma volumes in patients in
whom bilateral surgical evacuation was performed were
120.8 cm3 (right) and 123.3 cm3 (left). Unilateral evacu-
ation was performed in patients with mean hematoma
volumes of 136.6 cm3 (right) and 136.3 cm3 (left) (Table
1). Even though there were relatively high standard devia-
tions, this shows that the indication for surgical treatment
of bcSDHs was comparable across the groups.
A recent study concerning bcSDHs that included 264
patients showed an overall retreatment rate of 21.6%. Ad-
ditionally, unilateral evacuation of bcSDHs was identified
as an independent risk factor for surgical retreatment. The
authors did not find any predictors of contralateral retreat-
ment after unilateral evacuation.3 On the other hand, the
increased risk of injuring the underlying brain tissue or
missing a rather small cSDH has to be taken into account
when considering initial bilateral evacuation.
In our study, the retreatment rate after unilateral evacu-
ation of a bcSDH was 31.0% and was therefore signifi-
cantly higher than after bilateral evacuation (14.8%).
The ipsilateral reoperation rate after unilateral evacua-
tion of a bcSDH was only 9.5% (4 cases) and thus close to
the reoperation rate in unilateral cSDH shown in a recent
meta-analysis (11.5%).2 The contralateral retreatment rate
after unilateral evacuation was 21.4% (9 cases). Contralat-
eral retreatment became necessary due to a progression in
size of the untreated hematoma from a mean volume of
68.4 cm3 (± 24.2 cm3) before initial unilateral surgery to
148.6 cm3 (± 39.5 cm3) before retreatment. The decision of
whether to simultaneously evacuate the smaller hematoma
FIG. 2. Upper: CT scans obtained in a 92-year-old man with bcSDHs.
Despite relatively high absolute hematoma volumes of 80.6 cm3 on the
right side and 216.5 cm3 on the left side, the VR-ratio was only 0.37. The
patient underwent single–burr hole evacuation of the left-sided hema-
toma and placement of a closed drainage system. Lower: CT scans
showing complete remission of the contralateral right-sided hematoma
14 months after the unilateral evacuation. This case illustrates the limi-
tation of using only absolute hematoma volume numbers for decision
making to evacuate the contralateral hematoma.
in bcSDH is not based on any studies, and to date there
are no parameters that predict a contralateral progression
after unilateral evacuation.
In our study there was a statistically significant differ-
ence in the mean contralateral preoperative hematoma
volume between groups A (contralateral retreatment) and
B (no contralateral retreatment) (Fig. 1 left; Table 2). The
contralateral retreatment rate was only 3.6% if the con-
tralateral hematoma volume was under 40 cm3. While it
seems obvious that a larger hematoma will more likely
need surgery in the future, our data indicate a cutoff at
40 cm3 and 60 cm3 (Fig. 1 right). With a contralateral he-
matoma volume between 40 cm3 and 60 cm3 or over 60
cm3, the retreatment rates increased to 28.6% and 85.7%,
respectively.
One reason for the higher retreatment rate after uni-
lateral treatment could be a progression of the contralat-
eral hematoma due to a reduction in ICP owing to uni-
lateral evacuation. One could expect that the larger the
evacuated ipsilateral hematoma, the higher the pressure
relief on the contralateral side, and therefore the hema-
toma would be more likely to expand regardless of the
size of the contralateral hematoma. However, there was
no significant difference in ipsilateral hematoma volume
between group A and group B (121.0 cm3 vs 140.6 cm3;
Table 2). A possible explanation for this may be that the

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FIG. 3. CT scans obtained in two representative cases. A: CCT scan acquired in a 74-year-old man with bcSDHs. The hematoma
volumes on the left and right sides were 93.4 cm3 and 64.4 cm3, respectively (VR-ratio 0.69). Due to hemiparesis on the right side,
the patient was initially treated with unilateral left-sided hematoma evacuation through a craniotomy and a closed drainage system.
B: CCT scan showing bcSDHs in an 82-year-old man who barely exhibited any symptoms (hematoma volumes 149.6 cm3 [left] and
73.1 cm3 [right]; VR-ratio 0.49). The patient underwent left-sided single–burr hole craniostomy and placement of a closed drain-
age system. C and D: Scans obtained in the same patients as on A and B, respectively, showing progression of the contralateral
subdural hematoma 17 and 40 days after their initial surgery. The hematoma volumes have increased to 133.7 cm3 and 124.1 cm3,
respectively, making an additional evacuation necessary.

contralateral hematoma does not always have the ten-
dency to progress or is, at the time of unilateral surgery,
already regressing. The contralateral hematoma seems to
expand only when the elevated ICP is the main factor that
prevented it from doing so. Thus it seems to be a complex
relationship between both hematomas and the brain pa-
renchyma that needs to be analyzed. In the presence of
mass effect through a bcSDH, brain atrophy cannot easily
be assessed on imaging studies. Therefore, a ratio deter-
mined by dividing the volume of the smaller hematoma
by the volume of the larger hematoma was generated to
describe the relation between both hematomas and was
named VR-ratio by the authors. The VR-ratio works as
a possible surrogate parameter for the pressure relation
between both hematomas. The higher the VR-ratio the
closer was the volume of the contralateral, smaller he-
matoma to the larger one, which was large enough to
indicate the need for surgical evacuation. Furthermore,
this ratio draws the attention away from the absolute he-
matoma volumes to the relation of each side’s hematoma
volume. Absolute volume numbers are more dependent
on individual factors such as brain atrophy or the capacity
(elasticity) of the brain to compensate additional mass ef-
fect. The possibility of compensation for a distinct hema-
1232 J Neurosurg Volume 131 • October 2019
toma volume is different in every individual patient and
shows great variations. A small hematoma can produce
a distinct mass effect and cause symptoms in a young
patient, while, in the presence of brain atrophy, a rather
large hematoma can be compensated for easily. The VR-
ratio removes the individual factor from the equation and
produces an objective parameter to show the influence of
one hematoma on the other. In combination with the ab-
solute hematoma volumes, the VR-ratio tries to describe
the interaction of all intracranial components.
In patients in whom contralateral retreatment became
necessary, the VR-ratio was significantly higher (0.56 vs
0.21), with a cutoff value of 0.4 (a sensitivity of 1 and a
specificity of 0.91).
Figure 2 shows CT scans obtained in a patient who un-
derwent unilateral surgery because of rapid clinical dete-
rioration; the preoperative contralateral hematoma volume
was 80.6 cm3. Taking only the absolute numbers of the
hematoma volumes into account, this patient should have
initially undergone evacuation on both sides. The VR-ratio
in this patient was 0.37. In the presence of distinct brain
atrophy, however, this patient did not need a contralateral
reoperation and showed resorption of the hematoma with
conservative treatment.

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FIG. 4. Graph illustrating the preoperative hematoma volume of the smaller, contralateral hematoma and the VR-ratio for all
patients. The horizontal dotted line indicates a hematoma volume of 40 cm3 and the vertical dotted line indicates a VR-ratio of 0.4.
Patients needing contralateral retreatment after an initially unilateral evacuation of their bcSDHs (group A, red) are almost entirely
located in the upper right portion of the graph, meaning that these patients showed a contralateral hematoma volume exceeding
40 cm3 and a VR-ratio of at least 0.4. Patients who underwent initially bilateral evacuation of their bcSDHs (green) are mainly
located in the upper right section, meaning larger hematomas on both sides. In the bottom left portion of the graph are mostly
patients who underwent unilateral evacuation and did not need contralateral retreatment (group B, blue). The upper left area is
nearly empty because this would indicate a condition in which the sum of both hematoma volumes would reach fatal levels. In
contrast, the right bottom portion is spared because locations there would indicate patients with hematoma volumes of less than
40 cm3 on each side. Such small hematomas would probably not cause any symptoms and therefore the patients would not have
needed surgical evacuation.

In contrast to that, 3 patients who needed subsequent
contralateral retreatment after initial unilateral evacua-
tion had small contralateral hematoma volumes of 41.0
cm3, 42.2 cm3, and 37.8 cm3 but VR-ratios of 0.52, 0.4,
and 0.44, respectively. The latter two patients addition-
ally were relatively young (21.7 and 56.9 years) and had
no brain atrophy; despite having small bcSDHs, they had
distinct mass effect. Figure 3 shows 2 other patients ini-
tially treated with unilateral hematoma evacuation. Their
VR-ratio was at least 0.4, and both of them subsequently
needed contralateral retreatment.
Figure 4 shows the correlation between the volume of
the contralateral smaller hematoma and the VR-ratio in
patients who underwent unilateral or bilateral evacuation.
The figure illustrates how patients who needed contralat-
eral retreatment after initial unilateral evacuation had a
contralateral hematoma volume greater than 40 cm3 and
a VR-ratio greater than 0.4 in the vast majority of cases.
Such patients would probably have profited from initial bi-
lateral evacuation.
While the VR-ratio is produced by dividing one hema-
toma volume by the other, the ratio tries to characterize the
pressure relation of the intracranial compartments in the
presence of bcSDHs. The benefit of the VR-ratio, there-
fore, depends on the surgical indication. In this retrospec-
tive study, this decision was made by the neurosurgeon
on duty and was based on the presence of mass effect in
imaging studies and clinical symptoms. The decision of
whether or not bcSDHs should be treated surgically was
not an issue of this study.
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Scheichel et al.
Limitations
The primary limitation of this study is its retrospective
design.
Conclusions
To date, the decision of whether to perform bilateral
or unilateral drainage of bcSDHs is based on clinical and
radiological parameters, but reproducible objective mea-
surements are lacking. Our study provides evidence that
a primary bilateral evacuation should be considered if the
smaller hematoma is greater than 40 cm3 and the relation
between the smaller and larger hematoma volume (VR-
ratio) is greater than 0.4.
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Disclosures
The authors report no conflict of interest concerning the materi-
als or methods used in this study or the findings specified in this
paper.
Author Contributions
Conception and design: Scheichel. Acquisition of data: Scheichel,
Popadic. Analysis and interpretation of data: Scheichel. Critically
revising the article: Marhold, Scheichel. Reviewed submitted ver-
sion of manuscript: Marhold, Scheichel, Ungersboeck. Approved
the final version of the manuscript on behalf of all authors: Mar-
hold. Statistical analysis: Scheichel. Study supervision: Marhold.
Correspondence
Franz Marhold: University Hospital of St. Poelten, Lower Austria,
Austria. franz.marhold@stpoelten.lknoe.at.
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